| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,189 |
1,189 |
$60K |
| D0120 |
Periodic oral evaluation - established patient |
1,918 |
1,916 |
$50K |
| D1120 |
Prophylaxis - child |
1,161 |
1,161 |
$45K |
| D0272 |
Bitewings - two radiographic images |
1,291 |
1,289 |
$30K |
| D1206 |
Topical application of fluoride varnish |
990 |
990 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
438 |
437 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
52 |
37 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
71 |
71 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
35 |
25 |
$3K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$843.69 |